Health inspection·October 3, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to thoroughly investigate the allegations of abuse for one of two sampled residents (Resident 1). Residents Affected - Few * Resident 1 claimed he was hit in the head by a staff member. The facility failed to ensure other residents were interviewed by the facility's Abuse Coordinator. This failure had the potential to put Resident 1 and other residents at risk of not being protected against the alleged abuse. Findings: Review of the facility's P&P titled Abuse Reporting and Prevention dated 8/2018 showed all reported incidents of abuse will be investigated by the Abuse Coordinator or designee thoroughly and report the results to the appropriate agencies and personnel, and to include for the interview of the involved residents and other parties who have knowledge of the alleged incident documenting on the interview records. On 9/23/24 at 1455 hours, CDPH, L&C Program received the SOC 341 form dated 9/23/24. Review of the SOC 341 showed the allegation of abuse by Resident 1 that he was hit in the head by a staff member. Medical record review for Resident 1 was initiated on 10/2/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical Examination dated 12/18/23, showed Resident 1 could make needs known but could not make medical decisions due to dementia (a group of conditions characterized by impairment of thinking, judgement, and memory loss). On 10/3/24 at 1040 hours, a review of the facility's investigation file folder was conducted. The facility's documented the interviews and statements of the facility staff and Resident 1's interview. However, there was no documented evidence Resident 1's roommate and/or other resident were interviewed by the facility to identify other residents who were potentially subjected to abuse by the alleged perpetrator. Further review of the facility's conclusion letter showed a resident council meeting was conducted on 9/19/23, with the meeting minutes about the resident's knowledge about the allegation of abuse in the facility. However, the resident council meeting was held four days before the information about the allegation of abuse for Resident 1 was reported to the abuse coordinator. On 10/3/24 at 1100 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON stated as part of the investigative process, the alleged victim would be interviewed, and the interviews would be conducted with whoever had the knowledge of abuse, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056145 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)